title: Direct hemoperfusion with polymyxin B-immobilized cartridge in severe sepsis due to intestinal perforation: hemodynamic findings and clinical considerations in anticoagulation therapy.
abstract: BACKGROUND
  High levels of endotoxin have been reported as a risk factor for mortality in critical patients. Toraymyxin® is a column designed to remove circulating blood endotoxin by direct hemoperfusion widely used in Japan.
  
  
  OBJECTIVE
  To evaluate the effect of direct hemoperfusion with Toraymyxin® (DHP-PMX) as an adjuvant treatment in patients with severe sepsis due to intestinal perforation in terms of hemodynamic function and coagulation abnormalities.
  
  
  METHODS
  Prospective cohort study with a historical control group. Cohort 1: prospective cohort undergoing two sessions of DHP-PMX (n=14). Cohort 2: retrospective historical cohort (n=7). The anticoagulation regime was used according to the protocol of each centre and to the special conditions of each patient.
  
  
  RESULTS
  Mean norepinephrine dose was significantly reduced (0.9 ± 0.5 μg/kg/min pre-first DHP-PMX vs 0.3 ± 0.4 μg/kg/min post-second DHP-PMX treatment, p<0.05). Central venous pressure (CVP) and stroke volume variation (SVV) remained without significant changes during the study, as well as cardiac index (CI) in patients with initial CI ≥ 2.5 L/min/m2. CI significantly increased in patients with initial CI<2.5 L/min/m2 (2.1 ± 0.4 pre-first DHP-PMX vs 3.4 ± 0.4 pre-second DHP-PMX session, p=0.01). Mean platelet count pre-first and post-second DHP-PMX decreased significantly (213.9 x 10(3) ± 138.5 x 10(3) platelets/mm3 vs 91.0 x 10(3) ± 53.5 x 10(3) platelets/mm3, p=0.03), without significant changes during each DHP-PMX treatment. Patients did not experience bleeding nor complications derived from DHP-PMX treatments. Survival rates at 28 and 56 days did not differ significantly between cohort 1 and 2 (21.4% vs 42.9%; 42.9% vs 57.1%; respectively).
  
  
  CONCLUSIONS
  Performing two sessions of DHP-PMX treatment in a cohort of patients with abdominal sepsis is a feasible adjuvant therapeutic approach, safe in terms of coagulation abnormalities, can be done with different anticoagulation protocols, improves hemodynamic status and may impact on survival.
authors.affiliation: Intensive Care Medicine Department, Hospital Santiago, C/ Olaguibel, 29, 01004 Vitoria, Spain. franciscojavier.maynarmoliner@osakidetza.net
authors.forename: Javier
authors.initials: J
authors.lastname: Maynar
authors.forename: Fernando
authors.initials: F
authors.lastname: Martínez-Sagasti
authors.forename: Manuel
authors.initials: M
authors.lastname: Herrera-Gutiérrez
authors.forename: Francisco
authors.initials: F
authors.lastname: Martí
authors.forename: Francisco Javier
authors.initials: FJ
authors.lastname: Candel
authors.forename: Javier
authors.initials: J
authors.lastname: Belda
authors.forename: Sergio
authors.initials: S
authors.lastname: Castaño
authors.forename: José Ángel
authors.initials: JÁ
authors.lastname: Sanchez-Izquierdo
mesh_terms: D000136:Acid-Base Equilibrium; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation; D002302:Cardiac Output / Q000502:physiology; D002496:Central Venous Pressure / Q000502:physiology; D015331:Cohort Studies; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006464:Hemoperfusion / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units; D007416:Intestinal Perforation / Q000150:complications*; D007902:Length of Stay; D008297:Male; D018579:Patient Selection; D011112:Polymyxin B / Q000008:administration & dosage / Q000627:therapeutic use*; D011446:Prospective Studies; D018805:Sepsis / Q000188:drug therapy* / Q000209:etiology / Q000382:microbiology; D012772:Shock, Septic / Q000188:drug therapy; D013318:Stroke Volume / Q000502:physiology; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D014662:Vasoconstrictor Agents; D011112:Polymyxin B